Laser Treatment of Unwanted Hair
David J. Goldberg, Mussarrat Hussain
▲
Core Messages
 A wide variety of lasers can now
induce permanent changes in un-
wanted hair.
 Hair removal lasers are distinguished
not only by their emitted wave-
lengths, but also by their delivered
pulse durations, peak fluences, spot
size delivery systems, and associated
cooling.
 Nd:YAG lasers with effective cooling
represent the safest approach for the
treatment of darker skin.
 Complications from laser hair re-
moval are more common in darker
skin types.
 Pain during laser hair removal is gen-
erally a heat-related phenomenon
and is multifactorial.
 Laser treatment of nonpigmented
hairs remains a challenge.
History
Human hair, its amount and distribution, plays
an important role in defining appearance in
contemporary society. Hair also functions in
many mammals as a sensory organ, reduces
friction in certain anatomic sites, protects
against the environment by providing thermal
insulation and thermoregulation, aids in
pheromone dissemination, and plays both
social and sexual roles (Wheeland 1997).
Individuals, seeking consultation for the
removal of unwanted body hair, generally have
increased hair in undesirable locations sec-
4
ondary to genetics or medical conditions. These
individuals may be classified as having hir-
sutism or hypertrichosis. More commonly,
those seeking hair removal have hair that would
be considered normal in distribution and den-
sity. However, these individuals, for emotional,
social, cultural, cosmetic, or other reasons,
want the hair to be removed.
There has always been the need for an ideal
method of hair removal that is both practical
and effective. Traditional hair removal tech-
niques have included shaving, waxing, tweez-
ing, chemical depilation, and electrolysis.
In the early twentieth century, radiograph
machines were widely used for removal of facial
hair in women. Unfortunately, these treatments
were associated with a high risk of complica-
tions and the potential for subsequent treat-
ment-induced carcinogenesis.
Maiman, using a ruby crystal in 1960, devel-
oped stimulated laser emission of a 694-nm red
light. This was the first working laser, and it is
from this prototype that today’s lasers are
derived. Since 1960, research and technical
advances have led to modern day lasers. Leon
Goldman, the father of laser surgery, published
preliminary results on the effects of a ruby laser
for the treatment of skin diseases. Ohshiro et al.
noted hair loss from nevi after treatment with a
ruby laser (Ohshiro et al. 1983).
Early reports described the use of a CO2
laser to eliminate unwanted hair on flaps used
for pharyngoesophageal procedures. A continu-
ous-wave Nd:YAG laser has also been shown to
remove hair in urethral grafts All of this early
work described lasers using ablative techniques
with the effect of nonspecific vaporization of
skin cells. These methods are not commonly
used for hair removal today because of their
limited effectiveness as well as their commonly
 62 Chapter 4
induced permanent pigmentary changes and
scarring.
Selective Photothermolysis
A detailed understanding of laser-tissue inter-
action emerged in 1983 as the theory of selective
photothermolysis was conceived for the laser
4 treatment of pediatric port wine stains (Ander-
son et al. 1983)
The theory of selective photothermolysis led
to the concept of a laser-induced injury con-
fined to microscopic sites of selective light
absorption in the skin, such as blood vessels,
pigmented cells, and unwanted hair with mini-
mal damage to the adjacent tissues. To achieve
this selective effect, lasers would need to fulfill
three requirements:
1. They should emit a wavelength that is highly
absorbed by the targeted structure.
2. They should produce sufficiently high ener-
gies to inflict thermal damage to the target.
3. The time of tissue exposure to the laser
should be short enough to limit the damage
to the target without heat diffusion to the
surrounding tissues. This is known as the
thermal relaxation time (TRT).
These concepts revolutionized cutaneous laser
treatment and led to the development of success-
ful laser and light-based hair removal devices.
Extended Theory
of Selective Photothermolysis
The concept of selective photothermolysis (An-
derson et al. 1983) emphasizes both the selective
damage and minimum light energy require-
ments seen with current laser technology. How-
ever, the use of such a short pulse width laser
system may become inapplicable when the tar-
get absorption is nonuniform over a treatment
area. This may be seen when the actual target
exhibits weak or no absorption, yet other sur-
rounding portions of the target exhibit signifi-
cant absorption. If this is the case, the weakly
absorbing part of the target chromophore has
Laser Treatment of Unwanted Hair
to be damaged by heat diffusion from the highly
pigmented/strongly absorbing portion of the
chromophore (the heater or absorber). Such
nonspecific thermal damage evokes the concept
of thermal damage time (TDT). The TDT of a
target is the time required for irreversible target
damage with sparing of the surrounding tissue.
For a nonuniformly absorbing target structure,
the TDT is the time it takes for the outermost
part of the target to reach a target damage tem-
perature through heat diffusion from the heated
chromophore.
According to the concept of extended selec-
tive photothermolysis, target damage can still
be selective even though the TDT is many times
as long as the thermal relaxation time (TRT) of
the actual target.
This new extended theory of selective ther-
mal damage of nonuniformly pigmented struc-
tures in biological tissue postulates that the tar-
get is destroyed by heat diffusion from the
absorbing chromophore to the target but not by
direct heating from laser irradiation, as is seen
with selective photothermolysis. This theory
has now been applied to the treatment of
unwanted hair. Ultimately, the use of hair
removal lasers expanded rapidly with the sub-
sequent development of appropriate cooling
devices that minimized epidermal injury.
Physical Basis of Laser Hair Removal
Successful treatment of unwanted hair is depen-
dent on an understanding of the optical proper-
ties of the skin. It is these properties that deter-
mine the behavior of light within the hair shaft
and bulb, including the relative amount of
absorption of incoming photons.
Different physical factors including deliv-
ered fluence, wavelength, pulse duration, and
spot size diameter play an important role in
maximizing the efficacy and safety of laser-
assisted hair removal.
For optimal laser hair removal, one needs to
use an optimal set of laser parameters based on
anatomic and physical principles. This is deter-
mined by a time–temperature combination
with the ultimate effect being transfollicular
denaturation.
 Factors Affecting Efficacy/Results
Pulse Duration
Laser pulse width seems to play an important
role in laser-assisted hair removal. Thermal
conduction during the laser pulse heats a region
around each microscopic site of optical energy
absorption. The spatial scale of thermal con-
finement and resultant thermal or thermome-
chanical damage is therefore strongly related
to the laser pulse width. Q-switched laser
nanosecond pulses effectively damage individ-
ual pigment cells within a hair follicle by con-
finement of heat at the spatial level of melano-
somes (Zenzie et al. 2000). They can induce
leukotrichia and cause a temporary hair growth
delay, but do not inactivate the follicle itself.
On the other hand, lasers with longer pulse
durations not only allow gentle heating of the
melanosomes, but also target the entire follicu-
lar epithelium by allowing thermal conduction
from the pigmented hair shaft and pigmented
epithelial cells to the entire follicular structure.
Therefore, lasers emitting longer pulse
durations can achieve two goals: (1) Epidermal
melanosomes are preserved. This then helps to
preserve the epidermis. (2) Adequate heat diffu-
sion occurs to the surrounding follicle from the
light-absorbing melanized bulb and shaft.
The use of a longer laser-emitted pulse
width may necessitate the use of higher fluences
because the longer pulse now heats a larger vol-
ume of tissue. This may be of some benefit in
allowing higher fluences to be used on dark
skin types with both less risk of epidermal
injury and increased chances of transfollicular
damage.
Spot Size
Large diameter laser exposure spots (e.g.,
> 10 mm) are associated with substantially less
loss of energy intensity with depth of dermal
penetration as compared to small-diameter
exposure spots. This is because optical scatter-
ing by dermal collagen causes light to diffuse as
it penetrates into the dermis. The larger the
spot, the less is the associated scattering.
63
Fluence
In general, higher-delivered laser fluences lead
to better laser hair removal results. However,
the higher the utilized fluence, the greater the
discomfort and risk of complications. The effec-
tive fluence for any one area of hair is deter-
mined mainly by hair color, whereas the toler-
ated fluence is determined mainly by skin color.
The tolerance fluence can be increased sub-
stantially by various means, such as cooling the
skin surface before, during, and/or after the
optical pulse.
Factors Affecting Efficacy/Results
Hair Color
Hair color is genetically determined, and is a
result of both the type and amount of melanin
within the hair shaft. Melanin production occurs
only during the anagen phase, by melanocytes in
the bulb that transfer melanin granules to hair
keratinocytes. Distinct types of melanosomes
exist in hair of different colors. Dark hair con-
tains large numbers of eumelanin granules,
whereas light hair contains mostly pheomelanin.
Red hair contains erythromelanin granules that
are rich in pheomelanin. In gray hair, melano-
cytes show degenerative changes such as vacu-
oles and poorly melanized melanosomes,
whereas in white hair melanocytes are greatly
reduced in number or are absent.
Most individuals demonstrate greater
melanin density in their hair as compared to
their skin epidermis such that the absorption
coefficient of the hair shaft and bulb is roughly
2–6 times that of the epidermis. Thus, hair will
generally absorb more of the melanin-absorb-
ing wavelengths emitted from today’s laser and
light source hair removal systems.
Thus, color contrast between the epidermis
and the hair shaft are paramount in determin-
ing the optimal wavelengths and pulse duration
for successful treatment. For high contrast
(dark hair and light skin) high fluences, shorter
wavelengths, and relatively short pulse dura-
tions can be used without risking epidermal
injury. Conversely, low contrast areas (dark hair
 64 Chapter 4
and dark skin) require lower fluences, longer
wavelengths, and longer pulse durations for safe
treatment.
Growth Centers of Hairs
The hair follicle is a self-regenerating structure
and contains a population of stem cells capable
4 of reproducing themselves. It has been noted, at
least in animal models, that a complete hair fol-
licle can be regenerated even after the matrix-
containing hair follicle is surgically removed.
Although the dermal papilla is not technically
part of the actual hair, it remains a very impor-
tant site for future hair induction, and melanin
production in terminal hairs.
Long-term hair removal has been tradition-
ally thought to require that a laser or light
source impact on one or more growth centers of
hair. The major growth centers have always
been thought to be in the hair matrix. However,
research evaluating growth of new hair has
revealed that the matrix is not the only growth
center. New hairs may evolve from the dermal
papilla, follicular matrix, or the “bulge.” These
stem cells are usually found in a well-protected,
highly vascularized and innervated area, often
in close proximity to a population of rapidly
proliferating cells. They always remain intact
and, in fact, are left behind after hair plucking.
Stem cells are relatively undifferentiated both
ultrastructurally and biochemically. They have
a large proliferative potential, and are responsi-
ble for the long-term maintenance and regener-
ation of the hair-generating tissue. They can be
stimulated to proliferate in response to wound-
ing and certain growth stimuli.
Hair Cycle
All human hairs show various stages of hair
growth. The hair cycle is divided into three
stages: anagen, the period of activity or growth
phase; catagen, the period of regression or
regression phase; and telogen, the period of
quiescence or resting phase.
Anagen growth phase varies greatly (and
can last up to 6 years) depending on age, sea-
Laser Treatment of Unwanted Hair
son, anatomic region, sex, hormonal levels, and
certain genetic predispositions. It is these varia-
tions that have led to the tremendous disparity
in hair cycles reported by various investigators.
The catagen stage is relatively constant and
is generally of 3 weeks duration, whereas the
telogen phase usually lasts approximately
3 months.
The overall length of the hair is determined
primarily by the duration of the anagen phase.
Human hair appears to grow continuously,
because the growth cycles of different hair folli-
cles are in dysynchrony with each other.
The histologic appearance of a hair follicle
also differs dramatically with the stages of
growth. The anagen follicle penetrates deepest
in the skin, typically to the level of subcuta-
neous fat. Catagen is characterized by pyknotic
changes in the nuclei of the kerotinocytes, fol-
lowed by apoptosis of the transient portion of
the follicle. The entire transient portion (which
begins at the level of the insertion of arrector
pili muscle and extends to the deepest portion)
is absorbed, except for the basement mem-
brane. As the new anagen progresses, the sec-
ondary hair germ descends, enlarges, and begin
to produce a hair shaft.
Although reports of anagen duration, telo-
gen duration, and the percentage of telogen
hairs represent an inexact science, most discus-
sions of laser hair removal take into account dif-
ferent anatomic areas in terms of anagen and
telogen cycles.
It is the sensitivity of the anagen hair to a vari-
ety of destructive processes, including laser and
light source damage, that leads to a metabolic
disturbance of the mitotically active anagen
matrix cells. The response pattern is dependent
both on the duration and intensity of the insult.
Lin et al. (Lin et al. 1998) postulate that folli-
cles treated in the telogen phase show only a
growth delay for weeks, whereas, when those
follicles are treated in the anagen phase they
may be susceptible to lethal damage, may have a
growth delay, or may simply switch into telogen
phase. This could partly explain the growth
dynamics of the hair cycle. Repeated treatments
could lead to a synchronization of the anagen
phase by induction and/or shortening of the
telogen phase, which could increase the effec-
 Factors Affecting Efficacy/Results
tiveness of hair removal with each consecutive
treatment. Another explanation might be that
the follicle is not destroyed immediately, but
shows a growth arrest after only one (short-
ened) anagen cycle. Some have questioned the
assumption that effective laser hair removal is
determined solely by treating hairs in the ana-
gen cycle. These investigators suggest that
melanin within a hair follicle may be more
important than the actual time of treatment.
Cooling
Laser hair removal-associated epidermal cool-
ing can be achieved by various means, including
ice, a cooled gel layer, a cooled glass chamber, a
cooled sapphire or copper window, a pulsed
cryogen spray, or solid air flow.
Epidermal melanin and melanized hairs
present competing sites for absorption of light
energy. Selective cooling is essential to effec-
tively minimize photothermal-induced epider-
mal adverse effects. In addition, epidermal
cooling also permits higher fluences to be deliv-
ered to the treated follicular structures. Ideally,
the epidermal temperature should be signifi-
cantly but harmlessly decreased by the cooling
procedure, while the target follicular tempera-
ture should remain unchanged or changed
insignificantly. If this condition is not met, the
laser fluences must be increased to compensate
for the lower target temperature.
Age
In an isolated study a significant negative corre-
lation was noted between successful hair
removal and the age of the patients, suggesting
that hair removal was more effective in younger
patients. However, other studies on hair re-
moval have not found age to be a factor in deter-
mining efficacy.
Hormones
A number of hormones affect hair growth, with
thyroid and growth hormones producing a gen-
65
eralized increased growth in hair. Estrogens
have only minimal effects on hair growth.
Androgens are the most important determinant
of the type of hair distributed throughout the
body. The principal circulating androgen,
testosterone, is converted in the hair follicle
by 5-alpha reductase to dihydrotestosterone
(DHT), which stimulate the dermal papilla to
produce a terminal melanized hair. The effect of
androgens on hair growth is skin area-specific,
due to local variations in androgen receptor and
5-alpha reductase content). While the effect of
androgens on hairs (i. e., terminalization of vel-
lus hairs) will be more readily apparent in skin
areas with a greater numbers of hair follicles,
hair follicle density does not correlate with fol-
licular sensitivity to androgens. Some areas of
the body, termed nonsexual skin (e. g., that of
the eyelashes, eyebrows, and lateral and occipi-
tal aspects of the scalp), are relatively indepen-
dent of the effect of androgens.
Other areas are quite sensitive to androgens.
In these locations hair follicles are terminalized
even in the presence of relatively low levels of
androgens. Such areas include the pubic area
and the axilla, which begin to develop terminal
hair even in early puberty when only minimally
increased amounts of androgens are observed.
Finally, some areas of skin respond only to high
levels of androgens. These sites include the
chest, abdomen, back, thighs, upper arms, and
face. The presence of terminal hairs in these
areas is characteristically masculine, and if pres-
ent in women is considered pathological, i. e.,
hirsutism.
Hirsutism is defined as the presence in
women of terminal hairs in a male-like pattern.
This affects between 5% and 10% of surveyed
women. Hirsutism above all else should be
principally considered a sign of an underlying
endocrine or metabolic disorder, and these
patients should undergo a thorough evaluation.
The hormonal therapy of hirsutism consists of
medications that either suppress androgen pro-
duction, or block androgen action.
The main purpose of hormonal therapy is to
stop new hairs from growing and potentially
slow the growth of terminal hairs already pre-
sent. Although hormonal therapy alone will
sometimes produce a thinning and loss of pig-
 66 Chapter 4
mentation of terminal hairs, it generally will not
reverse the terminalization of hairs.
Currently Available Lasers and Light
Sources Used for Hair Removal
In the USA, the Food and Drug Administration
4 (FDA) has traditionally used electrolysis results
as a benchmark to evaluate laser treatment effi-
cacy, despite the near lack of significant scien-
tific data about electrolysis. In the initially sub-
mitted studies, all hair removal devices were
required to show a 30% decrease in hair growth
at 3 months after a single treatment (Tope et al.
1998).
This criterion clearly does not equate with
permanent hair loss, as a delay in hair growth,
which usually lasts for 1–3 months, is simply
consistent with the induction of the telogen
stage. Permanent hair reduction results should
be based on the cyclic growth phases for hair
follicles, and should refer to a significant reduc-
tion in the number of terminal hairs after a
given treatment. There must be a reduction that
is stable for a period of time longer than the
complete growth cycle of hair follicles at any
given body site.
Multiple laser systems are currently avail-
able and approved by the FDA for hair removal.
The lists below include the more popular sys-
tems. They are not meant to be all-inclusive.
Ruby Lasers
Ruby lasers (694 nm), used for hair removal
includes:
 Epilaser/E2000 (Palomar, Lexington, MA)
 EpiPulse Ruby (Lumenis, Santa Clara, CA)
 RubyStar (Aesculap Meditec., Irvine, CA)
Epilaser/E2000 (Palomar). With this laser,
light is delivered through a fiber, and two differ-
ent spot sizes (10 mm and 20 mm) are available.
A retroreflector is built into the hand piece,
allowing photon recycling and therefore higher
energy delivery (Anderson et al. 1999; Ross et al.
1996). Depending on skin type or hair thick-
Laser Treatment of Unwanted Hair
ness, a single pulse of 3 ms or twin pulses (i. e.,
two 3-ms pulses delivered with a delay of
100 ms) can be chosen. The E2000 uses a sap-
phire-cooled handpiece (Epiwand) to protect
the epidermis during laser irradiation. The sap-
phire lens is actively cooled to 0° or –10°C and
put in direct contact with the skin.
The long-pulsed EpiPulse Ruby laser (Lume-
nis) employs triple-pulse technology with
10-ms intervals between pulses. This train of
pulses keeps the follicle temperature sufficiently
high to cause destruction. Epidermal cooling is
achieved by applying a thick layer of cooled
transparent gel on the skin.
The RubyStar (Aesculap-Meditec) is a dual-
mode ruby laser that uses a contact skin cooling
method. It can operate in the nanosecond Q-
switched mode for the treatment of tattoos and
pigmented lesions and in the normal millisec-
ond mode for hair removal. Its integrated cool-
ing device consists of a cooled contact hand-
piece which precools the skin before laser pulse
delivery.
Although the mechanism of ruby laser
induction of follicular injury is likely to be ther-
mal, the precise contributions of photomechan-
ical damage or thermal denaturation to follicu-
lar injury are unknown. It is possible that after
absorption of radiant energy, the large temper-
ature differences between the absorbing mela-
nosomes and their surroundings produce a
localized rapid volume expansion. This would
then lead to microvaporization or “shock
waves,” which cause structural damage to the
hairs (Anderson et al. 1983). On the other hand,
thermal denaturation leading to melanosomal
damage is also possible. Histologic evaluation
of laser-treated mouse skin has revealed evi-
dence of thermal coagulation and asymmetric
focal rupture of the follicular epithelium (Lin
et al. 1998). Secondary damage to adjacent
organelles could theoretically result either from
thermal diffusion or from propagation of shock
waves.
Because of its comparatively short ruby
laser wavelength, this hair removal system is
best suited for the treatment of dark hair in
light skin. It also may be more efficacious than
longer wavelength devices for the treatment of
light hair or red to red-brown hair (Ross et al.
 Currently Available Lasers and Light Sources
1999). Because of the high melanin absorption
coefficient at 694 nm, the ruby laser must be
used with caution in darkly pigmented or tan
patients.
A number of reports have documented the
efficacy of ruby laser hair removal in varying
types of skin using different laser parameters.
The published hair reduction rates have ranged
from a 37% to 72% reduction 3 months after one
to three treatments to a 38%–49% hair reduc-
tion 1 year after three treatment sessions
(Williams et al. 1998). As would be expected,
multiple treatments at 3- to 5-week intervals
produce a greater degree of hair reduction than
is seen after a single session. In general, higher
delivered fluences do lead to better hair removal
success, although complications also increase.
Studies with larger numbers of patients have
confirmed that hair counts are reduced by
approximately 30% after a single treatment
with ruby laser (Williams et al. 1998). The
effects of multiple treatments sessions are addi-
tive, as hair counts are reduced by approxi-
mately 60% after three or four treatment ses-
sions. Whether 100% permanent hair removal
can be achieved remains open to debate.
Alexandrite Lasers
Several long-pulsed alexandrite lasers (755 nm)
are being used for hair removal, including:
 Apogee series (Cynosure, Chelmsford, MA)
 Epitouch ALEX (Lumenis, Santa Clara, CA)
 GentleLase (Candela, Wayland, MA)
The Apogee system (Cynosure) provides pulse
durations between 5 and 40 ms and fluences up
to 50 J/cm2. A cooling handpiece (SmartCool)
blows a continuous flow of chilled air into
the treatment area. The scanner option
(SmartScan) enables treatment of large areas
with an unobstructed view, speedy treatment,
and ease of use with minimal operator fatigue.
The Epitouch ALEX (Lumenis) delivers a
2-ms pulse duration, spot sizes of 5–10 mm, and
fluences of 10–25 J/cm2. A cooling gel is applied
to the skin before treatment, and a scanning
device can be used to treat larger body-surface
areas.
67
The GentleLase (Candela) delivers a 3-ms
pulse duration, spot sizes of 8–18 mm, and flu-
ences ranging from 10 to 100 J/cm2. It employs a
dynamic cooling device (DCD) to protect the
epidermis. The DCD cooling method uses short
(5–100 ms) cryogen spurts, delivered to the skin
surface through an electronically controlled
solenoid valve; the quantity of cryogen deliv-
ered is proportional to the spurt duration.
There are a number of advantages in using
long-pulsed alexandrite lasers for hair removal.
Some of the long-pulsed alexandrite laser sys-
tems are compact and can be used in small
rooms if adequate ventilation is available. Their
flexible fiberoptic arm is easy to manipulate and
provides access to hard-to-reach body areas.
The large spot sizes and frequency (1–5 Hz)
improves the possibility of rapidly treating
large body areas.
The alexandrite laser wave length of 755 nm
is absorbed about 20% less strongly by melanin
compared with the ruby laser wavelength of
694 nm. Its absorption by the competing chro-
mophore, oxyhemoglobin, is substantially in-
creased as compared to the 694-nm wavelength.
However, the longer wavelength of 755 nm pene-
trates more deeply into the dermis and is less
absorbed by epidermal melanin. This theoreti-
cally decreases the risk of epidermal damage,
especially in individuals with darker skin types.
Because dermal scattering decreases with
increasingly longer wavelengths, 755-nm light
penetrates deeper into tissue than does shorter
wavelengths. In theory, the use of longer wave-
lengths should increase the ratio of energy
deposited in the dermis relative to the epider-
mis. This would result in relatively increased
bulb heating while at the same time promoting
epidermal sparing (Ross et al. 1999).
The reported hair removal success rate
using an alexandrite laser has ranged from 40%
to 80% at 6 months after several treatments
(Gorgu et al. 2000) In a controlled randomized
study using a single 20 J/cm2, 5- to 20-ms
alexandrite laser on various anatomic sites,
investigators reported a 40% reduction in
hair growth 6 months after treatment. This
increased to > 50% (on the upper lip) if a sec-
ond treatment was performed after 8 weeks. In
another study, one treatment with a variable
 68 Chapter 4
pulsed alexandrite laser produced maximum
hair growth reduction at 6 months of 40%–56%
for the lip, leg, and back. Finally, one study has
noted a mean 74% bikini hair reduction 1 year
after five alexandrite laser treatments.
Diode Lasers
4 Diode lasers (800 nm) used for hair removal
include:
 LightSheer (Lumenis, Santa Clara, CA)
 Apex-800, (Iriderm, Mountain View, CA)
 LaserLite, (Diomed, Boston, MA)
 SLP 1000 (Palomar Medical Technologies,
Lexington, MA)
 MeDioStar (Aesculap-Meditec, Irvine, CA)
 EpiStar (Nidek, Freemont, CA)
Although the myriad diode lasers vary in their
delivered energies, spot sizes, pulse duration,
and associated cooling devices, they all set a
popular standard for efficiency, reliability, and
portability.
Because of reduced scattering at the longer
810-nm diode wavelengths, light from the diode
laser penetrates more deeply into the skin. At
800 nm, 24% of incident fluence reaches a
depth of 3 mm, whereas only 5% reaches the
same depth with 700-nm light (Ross et al. 1999).
Also, 800-nm energy is 30% less absorbed by
melanin than that of the ruby laser, yet the 800-
nm wavelength leads to better optical penetra-
tion.
In general, the diode laser system has been
found to be better tolerated by patients with
darker skin types (V–VI) as compared to the
ruby laser (Adrian et al. 2000). This is likely due
to its longer wavelength, longer pulse width,
and associated active cooling.
In a prospective controlled trial, the 810-nm
diode laser demonstrated a significant reduc-
tion in hair growth (Lou et al. 2000). Overall,
clinical studies with the diode laser system have
reported variable success rates ranging from
65–75% hair reduction at 3 months after one to
two treatments with fluences of 10–40 J/cm2.
This was increased to > 75% hair reduction in
91% of subjects 8 months after three to four
treatments at 40 J/cm2 (Williams et al. 1999). As
Laser Treatment of Unwanted Hair
expected, repeated treatments, generally at 4-
week intervals, appears to improve results (Lou
et al. 2000).
Nd:YAG Lasers
Millisecond Nd:YAG lasers (1064 nm) used for
hair removal include:
 Lyra (Laserscope, San Jose, CA)
 CoolGlide (Cutera, Brisbane, CA)
 Yaglase (Depilase, Irvine, CA)
 Image (Sciton, Palo Alto, CA)
 VascuLight (Lumenis, Santa Clara, CA)
The longer Nd:YAG laser wavelength provides
deeper penetration, a necessary factor in the
attempt to achieve optimal laser hair removal
results. In addition, the 1064-nm wavelength is
relatively less absorbed by epidermal melanin
than are the 694- to 810-nm wavelengths. It is
this decreased melanin absorption that leads to
the greater pigmented epidermal safety seen
with these systems.
Although the 1064-nm wavelength is less
well absorbed by melanin than shorter wave-
lengths, the absorption appears to be enough to
achieve the selective photothermolysis of the
pigmented hair follicle (Lin et al. 1998). The use
of appropriate fluences and effective epidermal
cooling devices leads to an effective hair
removal device with little risk of complications
when such lasers are used correctly. Although
the relatively low melanin absorption would
appear to be a disadvantage in the treatment of
pigmented hair, the Nd:YAG laser’s advantage is
its ability to reduce the thermal damage of the
laser-treated melanin containing epidermis.
Thus, side effects are decreased in darker-
skinned patients).
Although Nd:YAG laser treatment usually
leads to less dramatic results when compared to
other laser systems available for hair reduction,
its 1064-nm wavelength decreased absorption
by melanin may also cause a lesser incidence of
epidermal side effects, including blistering and
abnormal pigmentation (Nanni et al. 1999).
Short-term hair reduction in the range of
20%–60% has been obtained with the long
pulsed Nd:YAG lasers.
 Currently Available Lasers and Light Sources
Early clinical studies have demonstrated less
hair reduction/laser session with Nd:YAG lasers
as compared to the published results with either
ruby or alexandrite lasers
However, preliminary studies suggest that
newer, high powered long-pulsed Nd:YAG lasers
may provide hair loss comparable to that seen
with other devices. The long-term efficacy and
precise role of the long-pulsed Nd:YAG lasers
remains to be established.
Q-Switched Nd:YAG Laser
Q-switched Nd:YAG lasers have been used to
target topically applied carbon particles that
have previously been applied to the hair follicle.
This method was one of the first available laser
hair removal techniques. This short term hair
removal technique has also been used without
the prior application of carbon.
Immediately after Q-switched 1064-nm
laser irradiation of carbon coated hairs, the car-
bon is heated to its vaporization temperature of
about 3,700 °C. Vaporization leads to a huge vol-
ume expansion with resultant supersonic prolif-
eration of high pressure waves. These shock
waves, in turn, produce mechanical damage, as
well as the development of heat. It is not clear
how much mechanical and/or heat energy pro-
duced by this mechanism is required for
destruction of a hair follicle. However, histo-
logic evidence of follicular damage is seen after
such a laser exposure. This results in a clinical
delay of hair growth.
Depending on the position and amount of
the topically applied chromophore, as well as
the energy administered, it may be possible to
occasionally irreversibly damage a hair follicle
even with a Q-switched laser.
Histologic studies have documented the
presence of carbon in the follicle after low flu-
ence Nd:YAG lasing. This carbon appears to
penetrate superficially in a large number of fol-
licles with and without a hair shaft in place;
deep follicular penetration is rare. The disad-
vantages of this technique, therefore, appear to
relate to the fact that that the carbon granules
may not consistently reach the requisite hair
bulge or bulb.
69
Different studies have compared the effec-
tiveness of Q-switched Nd:YAG laser hair
removal with ruby and alexandrite laser treat-
ments. Millisecond pulse ruby and alexandrite
lasers showed greater hair reduction than was
seen with Q-switched Nd:YAG lasers. Relatively
weak absorption by the innate target chro-
mophore melanin of Q-switched Nd:YAG laser
energy translates into less energy available to
damage the follicle. Therefore, a lesser hair
removal effect is seen.
Several studies have examined the 1064-nm
Q-switched Nd:YAG laser with and without a
topically applied chromophore. However, in one
controlled study (Nanni et al. 1997), using a sin-
gle Q-switched Nd:YAG laser treatment, 100%
hair regrowth was observed at 6 months irre-
spective of the treatment. Although capable of
inducing delayed regrowth, Q-switched Nd:YAG
laser treatment appears to be ineffective at pro-
ducing long-term hair removal.
Intense Pulsed Light Systems
Intense pulsed light (IPL) systems are high
intensity pulsed light sources which emit poly-
chromatic light in a broad wavelength spectrum
of 515–1200 nm. The emitted wavelengths deter-
mine not only the absorption pattern of the
emitted light but also the penetration depth of
the light. With the aid of different cut-off filters
(515–755 nm), which only allow a defined wave-
length emission spectrum, the optimal wave-
length spectrum can be filtered to correspond
to the depth of the target structure (i. e., hair fol-
licles). Similarly, the emitted wavelengths can
be adopted to the patient’s individual skin type.
Higher cutoff filters reduce the emission of
melanin-absorbing wavelengths; thus being
safer for darker skin types.
The pulse duration of IPL systems can be set
to a wide range of parameters. The use of single
pulses is possible. In the alternative, high flu-
ences can be divided into multiple pulses. The
intervals between individual pulses can be set at
values between 1 and 300 ms. This delay, in the-
ory, allows the epidermis and smaller vessels to
cool down between pulses while the heat is
retained in the larger target (hair follicles). This
 70 Chapter 4
results in selective thermal damage. The extent
of maximum delivered fluences and the spot
size vary, depending on utilized IPL.
When an IPL is used, a transparent refriger-
ated gel is placed on the skin to cool the epider-
mis and to improve light delivery to the skin
during treatment. The large rectangular spot
sizes associated with most IPL hand pieces
allows a large number of hairs to be treated
4 simultaneously.
The IPL delivery of a broad range of wave-
lengths has some advantages. The presence of
longer wavelengths provides better penetration
depth into the dermis, while shorter wave-
lengths can be filtered out to protect the epider-
mis in darker-skinned individuals. Shorter
emitted wavelengths may also be useful to treat
red-brown hair (Ross et al. 1999).
One of the greatest technical advantages of
IPL systems is the large exposure area that is
used. This improves the resultant damage of
deep follicles. A disadvantage is that the rectan-
gular spot size prevents treatment of hair-bear-
ing areas on marked convexities or concavities
(Ross et al. 1999).
Several studies have demonstrated the long-
term efficacy of IPL hair removal devices (Gold
et al. 1997; Weiss et al. 1999). In one study of 67
subjects of Fitzpatrick skin phototypes I-IV,
mean hair loss was 48% at 6 months or more
after a single treatment. In another study, after
a single treatment, hair reduction ranging
from 33% to 60% was observed at 6 months
after treatment. Further studies of 14 subjects
treated with this technology and followed for
> 12 months after their last treatment showed a
mean of 83% hair reduction was obtained after
two to six treatments. As would be expected,
repeated treatments appear to improve out-
come. Despite this, some have suggested that
more than three IPL treatments do not appear
to increase the success rate. Not all would agree
with this. Finally, treatment with IPL, with and
without bipolar radiofrequency, has been said
to be useful for the treatment of light-colored
hair. Generally, more treatments are required
and the results are not expected to be as good as
those seen when treating darker-colored hairs.
Laser Treatment of Unwanted Hair
Advantages
Laser-assisted hair removal is now an accepted
successful treatment for the removal of un-
wanted hair. It has been proven to be more
effective than electrolysis and clearly represents
the best method for removing large areas of
hair in a relatively short period of time.
Disadvantages
The theoretical explanations behind laser-
assisted hair removal seem logical. However,
questions do remain. It is very difficult to pre-
dict the ideal patient and ideal treatment
parameters for each patient. Even the same
patient may respond differently to the same
parameters on two different treatment sessions.
It is impossible to estimate the exact amount
of energy absorbed by each hair follicle after
laser irradiation owing to skin nonhomogene-
ity, multilayering, and anisotrophic physical
properties of hair growing at different angles
in relation to the laser impact. In addition,
because growing hair depths vary between 2
and 7 mm depending on the body location, laser
absorption characteristics will vary depending
on the anatomic site. Finally, the percentage of
anagen and telogen hairs varies from site to site,
from person to person, and from season to sea-
son. It is not even clear whether the treatment of
anagen as compared to catagen or telogen hairs
even matters.
Many studies now show the hair follicle to
be an incredibly resilient structure, regrowing
after a seemingly lethal injury. It is the delivery
of adequate fluences, optimizing wavelengths,
and pulse durations, while reducing unwanted
epidermal injuries that leads to the optimal
treatments of pigmented hair. Unfortunately,
the treatment of unwanted light or white hairs
remains a challenge.
Indications
Individuals may seek laser hair removal because
of excess hair induced by genetics or associated
 Personal Laser Approach
medical conditions. More commonly, laser hair
removal patients simply have unwanted hair
that would be considered normal in distri-
bution and density. Yet, these individuals for
emotional, social, cultural, cosmetic, or other
reasons want the hair to be removed. Also, indi-
viduals with pseudofolliculitis barbae, a rela-
tively common disorder seen with coarse, curly
hairs that occurs in glabrous skin, often seek
laser hair removal.
The ideal candidate for laser hair removal is
a dark-haired, fair-skinned individual with little
melanin within the overlying epidermis. Such
patients tolerate the use of more effective higher
fluences and relatively shorter wavelengths. In
darker-skinned individuals it may be preferable
to utilize a longer wavelength laser device. Epi-
dermal protection is also afforded by utilizing
longer pulse durations and active cooling.
Contraindications
There are a number of relative contraindica-
tions that the laser physician should consider
before treatment. The physician should ascer-
tain that the patient has realistic expectations
from the laser treatment. Patients with a history
of hypertrophic or keloidal scarring should be
treated more conservatively, using test spots
and lower fluences. Likewise, patients with a
history of recent isotretinoin use should be
treated less aggressively.
Any patient with a history of herpes simplex
infections should be given prophylactic antivi-
ral therapy prior to any laser treatment at that
anatomic site. Patients who regularly take
aspirin or anticoagulant therapy should discon-
tinue taking these medications at least 10 days
prior to treatment, if possible. If these medica-
tions are not discontinued, patients may have
more bruising, as these medications can predis-
pose to vessel extravasation after treatment. It is
recommended that patients having a history of
persistent postinflammatory hyperpigmenta-
tion, darkly tanned skin, or skin types greater
than Fitzpatrick phototype III, not be treated
with lasers having shorter wavelengths, as such
individuals are at a greater risk of postinflam-
matory hyperpigmentation.
71
Patients having photosensitivity disorders,
or using systemic medications known to be
photosensitizing, should be carefully screened.
Although laser treatment in itself is inher-
ently safe in pregnancy, the treatment does
cause pain and can be distressing, and is best
deferred in some patients until after delivery.
All patients should be instructed to postop-
eratively avoid sun exposure and wear a broad
spectrum sunscreen of SPF 30 or higher on
treated exposed areas.
Consent
Informed consent is mandatory and should
include treatment options, potential reasonable
risks and benefits. One should avoid any guar-
antees. Figure 4.1 is a suggested consent for
laser/light source hair removal.
Personal Laser Approach
Alexandrite Laser
Most individuals are no longer using ruby
lasers. However, the same general approach to
alexandrite laser treatments would apply if the
ruby laser was used for hair removal in lighter
skin types. We have found the alexandrite lasers
to be very helpful in treating Fitzpatrick I–III
skin phenotypes (Figs. 4.2–4.14). Although it
has been suggested that alexandrite lasers, with
their longer 755-nm wavelength, are safer in
treating darker complexions than are ruby
lasers, we have not consistently found this to be
the case. It would appear that the ability to treat
darker complexions with alexandrite lasers may
be more related to the longer pulse durations
emitted by some of these systems. It should be
noted that unless appropriate cooling is uti-
lized, some Fitzpatrick skin phenotype III and
even sun-tanned type II complexioned indivi-
duals tend to have postinflammatory pigmen-
tary changes after laser treatment.
 72 Chapter 4 Laser Treatment of Unwanted Hair

OPERATIVE CONSENT: LASER/LIGHT SOURCE HAIR REMOVAL

Patient . . . . . . . . . . . . . . . . . . . . . . Date . . . . . . . . . . . . . . . . . . . . . . . .

I am aware that laser/light source hair removal is a relatively new procedure. My doctor has explained to
me that much of what has been written about these methods in newspapers, magazines, television, etc.
4 has been sensationalized. I understand the nature, goals, limitations, and possible complications of this
procedure, and I have discussed alternative forms of treatment. I have had the opportunity to ask ques-
tions about the procedure, its limitations and possible complications (see below).

I clearly understand and accept the following:

1. The goal of these surgeries, as in any cosmetic procedure, is improvement, not perfection.
2. The final result may not be apparent for months postoperatively.
3. In order to achieve the best possible result, more than one procedure will be required. There will be a
charge for any further operations performed.
4. Strict adherence to the postoperative regimen (i.e., appropriate wound care and sun avoidance) is
necessary in order to achieve the best possible result.
5. The surgical fee is paid for the operation itself and subsequent postoperative office visits. There is no
guarantee that the expected or anticipated results will be achieved.

Although complications following laser/light source hair removal are infrequent, I understand that the
following may occur:
1. Bleeding, which in rare instances could require hospitalization.
2. Infection is rare, but should it occur, treatment with antibiotics may be required.
3. Objectionable scarring is rare, but various kinds of scars are possible.
4. Alterations of skin pigmentation may occur in the areas of laser surgery. These are usually temporary,
but rarely can be permanent.
5. A paradoxical increased hair growth may occur at or near treated sites. This generally responds to
further treatments.

This authorization is given for the purpose of facilitating my care and shall supersede all previous autho-
rizations and/or agreements executed by me. My signature certifies that I understand the goals, limita-
tions and possible complications of laser surgery, and that I wish to proceed with the operation.

. . . . . . . . . . . . . . . . . . . . . . . . . .
Patient

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Witness Date

Fig. 4.1. Consent form

 Personal Laser Approach
Fig. 4.2. Before alexandrite laser hair removal
Fig. 4.4. Before alexandrite laser hair removal
Diode Laser
We have found the 810-nm diode lasers very
useful in treating Fitzpatrick I–IV skin pheno-
types (Figs. 4.15–4.18). The laser should always
be used with a cooling device. When used with
the longer emitted 30-ms pulse durations, some
darker Fitzpatrick skin phenotypes can be
treated with a lessening of postinflammatory
pigmentary changes. Diode systems are small,
portable and very user-friendly.
73
Fig. 4.3. Six months after five alexandrite hair
removal sessions
Fig. 4.5. Six months after five alexandrite hair
removal sessions
As a general rule, somewhat lower fluences
are required for effective hair removal than are
required with the ruby lasers. This may be
related to the deeper penetration of the 800-nm
wavelength.
Nd:YAG Laser
We have found the nanosecond Q-switched
Nd:YAG lasers to be highly effective in inducing
 74 Chapter 4 Laser Treatment of Unwanted Hair

Fig. 4.6. Before alexandrite laser hair removal Fig. 4.7. Six months after three alexandrite hair
removal sessions

Fig. 4.8. Nine months after three alexandrite hair Fig. 4.9. Before alexandrite laser hair removal
removal sessions
 Personal Laser Approach 75

Fig. 4.10. Six months after three alexandrite hair Fig. 4.11. Nine months after three alexandrite hair
removal sessions removal sessions

Fig. 4.12. Before alexandrite laser hair removal Fig. 4.13. Six months after three alexandrite hair
removal sessions
 76 Chapter 4 Laser Treatment of Unwanted Hair

temporary short-term hair removal. Skin cool-

ing is not required when a nanosecond laser is
used. This contrasts with the requisite need for
some form of epidermal cooling with virtually
all millisecond hair removal lasers.
When the Q-switched Nd:YAG laser tech-
nique is utilized with a topical carbon suspen-
sion, there is often a greenish hue to the area
being treated when visualized through goggles.
4 This is presumably due to the interaction
between the 1064-nm wavelength and the
carbon chromophore. When the 1064-nm Q-
switched Nd:YAG laser is used without topical
carbon chromophore, dark terminal hairs often
turn white on laser impact. Usually no post-
Fig. 4.14. Nine months after three alexandrite hair
removal sessions

Fig. 4.15. Before diode laser hair removal Fig. 4.16. Six months after two diode hair removal
sessions

Fig. 4.17. Before diode laser hair removal Fig. 4.18. Six months after five diode hair removal
sessions
 Personal Laser Approach
Fig. 4.19. Before Nd:YAG laser hair removal
Fig. 4.21. Before IPL hair removal
treatment crusting is noted. Erythema may vary
from nonexistent to significant in its extent. It is
quite safe to treat individuals who have darker
complexions with nanosecond Q-switched
Nd:YAG laser.
Millisecond Nd:YAG laser systems are the
safest laser hair removal systems for Fitzpatrick
skin types V–VI (Figs. 4.19, 4.20). Although they
can also be used for lighter skin types, we have
not found the same degree of success when
these lasers are compared to the shorter wave-
length systems. Although postinflammatory
pigmentary changes from this laser are rare,
such changes can be occasionally expected in
some individuals with dark complexions.
77
Fig. 4.20. Six months after five Nd:YAG laser hair
removal sessions. Note not only decreased hair but
also improvement in pseudofolliculitis barbae
Fig. 4.22. Six months after three IPL hair removal
sessions
IPL
We have found intense pulsed light sources to be
useful in treating Fitzpatrick I and IV skin phe-
notypes (Figs. 4.21–4.24). Although some IPL
sources are FDA cleared in the USA for Fitz-
patrick skin phenotypes V, we have found that
the incidence of postinflammatory changes may
be too high for practical use in some of these
individuals. In choosing emitted pulse dura-
tions, we have noted that shorter pulse durations
are more helpful for finer hairs, while longer
pulse durations appear to have greater efficacy in
treating thicker hairs. In addition, longer pulse
durations, because of their epidermal pigment
sparing capacity, are chosen for darker skin phe-
notypes. The choice of pulsing mode and inter-
 78 Chapter 4
Fig. 4.23. Before IPL hair removal
pulse times are also dictated by complexion.
Darker complexions are usually treated with a
double/triple pulse and longer interpulse times,
in comparison with the parameters chosen with
lighter skin complexions. As is true for all lasers
used for hair removal, the higher the fluences, the
better the results. The fluence chosen should be
as high as can be tolerated without creating an
epidermal blister.
Intense pulsed light sources have shown the
greatest safety when used with optimal skin
cooling.
Treatment Approach
The hair removal treatment technique with all
lasers and intense pulsed light sources com-
mences with preoperative shaving of the treat-
ment site. This reduces treatment-induced
odor, prevents long pigmented hairs that lie on
the skin surface from conducting thermal
energy to the adjacent epidermis, and promotes
transmission of laser energy down the hair fol-
licle. A small amount of posttreatment crusting
and erythema is to be expected. In darkly pig-
mented or heavily tanned individuals, it may be
beneficial to use topical hydroquinones and
meticulous sunscreen protection for several
weeks prior to treatment in order to reduce
inadvertent injury to epidermal pigment. Indi-
viduals with recent suntans should not be
treated until pretreatment hydroquinones have
been used for at least 1 month. Postinflamma-
Laser Treatment of Unwanted Hair
Fig. 4.24. Six months after three IPL hair removal
sessions
tory pigmentary changes are still to be expected
in individuals who have darker complexions.
All of the lasers and intense pulsed light
sources described in this chapter, when used
with almost all fluences, can lead to temporary
hair loss at all treated areas. However, choosing
appropriate anatomic locations and using higher
fluences will increase the likelihood of perma-
nent hair reduction after multiple treatments.
Even though permanent hair loss is not to be
expected in all individuals, lessening of hair
density and thickness is an expected finding.
The ideal treatment parameters must be
individualized for each patient, based on clini-
cal experience and professional judgment. For
individuals who have darker complexions, the
novice might consider delivering the laser
energy in several individual test pulses at an
inconspicuous site with lower energy fluences.
The delivered energies are then slowly in-
creased. Undesirable epidermal changes such as
whitening and blistering are to be avoided.
Prolonged and permanent hair loss may
occur following the use of all the aforemen-
tioned described millisecond systems. However,
great variation in treatment results is often
seen. Most patients with brown or black hair
obtain a 2- to 6-month growing delay after a
single treatment. There is usually only mild dis-
comfort at the time of treatment. Pain may be
diminished by the use of topical or injected
anesthetics.
Transient erythema and edema are also
occasionally seen and irregular pigmentation of
 Complications
1- to 3-months duration is often noted. These
changes are far less common after treatment
with an Nd:YAG laser. Permanent skin changes,
depigmentation, or scarring is rare.
Finally, it is true for all hair removal lasers
that the higher the delivered fluences, the better
the results. The fluence chosen should be as
high as can be tolerated without creating an epi-
dermal blister.
Postoperative Considerations
The use of ice packs may reduce postoperative
pain and minimize swelling. Analgesics are usu-
ally not required unless extensive areas are
treated. Prophylactic courses of antiviral agents
should be considered in patients with a history
of herpes simplex infections in the to-be-
treated area. Topical antibiotic ointment applied
twice daily is indicated if posttreatment epider-
mal injury occurred. Mild topical steroid
creams may be prescribed to reduce swelling
and erythema. Any trauma, such as picking or
scratching of the area, should be avoided. Dur-
ing the first week of healing, sun exposure
should be avoided or sunblocks used. Make-up
may be applied on the next day unless blistering
or crusts have developed. The damaged hair is
often shed during or after the first week of the
treatment. Patients should be reassured that
this not a sign of hair regrowth.
Complications
The incidence of cutaneous adverse effects after
laser hair removal is both patient and laser
parameter related. Patients with darker-colored
skin, especially skin types V and VI, are more
likely to experience cutaneous adverse effects,
related to the abundance of melanin in their
epidermis. However, such complications are not
limited to patients with genetically determined
dark skin. This may also be seen in patients
with darker skin due to other reasons, such as
sun-tanning and lentiginous photoaging. The
incidence of adverse effects will be modified by
utilized wavelength, fluence, pulse duration,
and associated cooling.
79
Pigmentary Changes
There is a remarkable variation in the reported
incidence of postoperative pigmentary changes
after laser hair removal. Unfortunately most
studies have not been carried out under stan-
dardized conditions. In different studies, varied
laser parameters have been used, follow-up
periods have varied from 90 days to 2 years, and
the preoperative skin characteristics were not
standardized (hair color, skin pigmentation,
anatomical region). Finally, the majority of
studies estimate the incidence of side effects by
subjective clinical evaluation.
In general, laser-induced pigmentary
changes depend on the degree of preoperative
pigmentation. Lighter skin types potentially
experience more postoperative hyperpigmenta-
tion. Darker skin types experience more sub-
clinical hypopigmentation. This finding is in
accordance with the fact that laser light in dark-
skinned types is strongly absorbed by the epi-
dermal melanin, leading to potential mela-
nocytic damage (Anderson 1994). Conversely,
thermal effects in lighter skin may provoke
postinflammatory hyperpigmentation.
Hypopigmentation
Transient posttreatment hypopigmentation
occurs in 10%–17% of patients (Grossman et al.
1996; Bjerring et al. 1998; Williams et al. 1998).
The exact etiology of postlaser hair removal-
induced hypopigmentation is unclear, but may
be related to the destruction of melanocytes,
suppression of melanogenesis, or the redistri-
bution of melanin in the keratinocytes.
Hyperpigmentation
Transient posttreatment hyperpigmentation
occurs in 14%–25% of patients (Grossman et al.
1996; Bjerring et al. 1998; Williams et al. 1998),
and is normally related to melanocytic-induced
stimulation. The causes of this hyperpigmenta-
tion include delayed tanning, epidermal injury,
or an immediate pigment darkening phe-
nomenon resulting from photo-oxidation of
 80 Chapter 4
pre-existing melanin. The darkening is usually
transient, lasting only 3–4 weeks and resolves
without sequelae in most individuals (McDaniel
1993).
A potentially more serious hyperpigmenta-
tion resulting from epidermolysis and blister-
ing can occur at energy thresholds higher than
those associated with immediate pigment dark-
ening. This can be associated with permanent
4 dyschromia.
Pain
Laser and light source heat-induced destruction
of hair follicles is not pain free, as the hair folli-
cle is well endowed with pain fibers arranged in
a well-organized neovascular bundle. The
intensity of pain varies with the delivered flu-
ence, utilized wave length, pulse duration, spot
size, repetition rate, laser interpulse spacing,
and skin pigmentation. Regional body areas
such as the lip and groin, and chronically sun-
exposed and tanned areas, also have been asso-
ciated with greater amounts of pain perception.
In addition, with increasing pulse duration,
heat diffusion is likely to raise the temperature
around the follicle and increase the level of
pain. Finally, pain can be perceived differently
at different times of the month. During men-
struation, the skin appears to be more sensitive
to pain and laser hair removal can be more
uncomfortable.
Scarring and Textural Changes
Despite the presence of severe macroscopic
cutaneous damage, collagen and elastin net-
works in the dermis are found to be normal in
the majority of the laser hair removal-treated
patients. Scarring can occur, but is rare.
Effects on Tattoos and Freckles
Lightening of tattoos and loss of freckles or pig-
mented lesions after laser-assisted hair removal
are common. Patients should be made aware of
this possibility.
Laser Treatment of Unwanted Hair
Infections
Herpes simplex infections are uncommon after
laser and light source treatment of hair
removal, but may occur, especially in patients
with strong prior history of outbreaks. Erup-
tions most commonly are seen on or around the
lip. Although the risk of bacterial infection is
extremely low, it may occur if there is laser-
induced epidermal damage.
Plume
The plume generated by the vaporized hair
shaft has a sulphur smell and in large quantities
can be irritating to the respiratory tract. A
smoke evacuator is advised.
The Future
The incredible amount of attention attracted by
laser and light source hair removal techniques
reflects a demand for more practical, tolerable,
effective, and safer epilation techniques. At this
time, effective light and white hair removal
techniques do not exist. Research into tech-
niques that light activate hair may be a part of
the future treatment of nonpigmented hairs.
References
Adrian RM, Shay KP (2000) 800 nanometer diode laser
hair removal in African American patients: a clini-
cal and histologic study. J Cutan Laser Ther 2:
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Altshuler GB, Anderson RR, Smirnove MZ, et al (2001)
Extended theory of selective photothermolysis.
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Anderson RR (1994) Laser-tissue interactions. In: Bax-
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Anderson RR, Dierickx CC, Altshuler GB, et al (1999)
Photon recycling. A new method of enhancing hair
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